Evaluation and management of chronic pulmonary thromboembolic disease.

Hosp Pract (Minneap). 2011 Aug;39(3):50-61

Authors: Mendoza V, Scharf ML

Abstract
Pulmonary embolism (PE) is common and the majority of patients survive the acute event. Survivors are at increased risk for adverse outcomes, including persistent thrombi, recurrent embolism, chronic thromboembolic pulmonary hypertension (CTEPH), and death. Anticoagulation protects against recurrence, which has a high mortality rate. The recommended duration of anticoagulation for patients with reversible PE risk factors is 3 months. For patients with idiopathic PE or persistent risk factors, extended duration of anticoagulation is preferred, balanced with an individual patient's risk of hemorrhage, which in itself is a major cause of morbidity and mortality. Among patients with malignancy who develop venous thromboembolism (VTE), low-molecular-weight heparin is preferred over oral vitamin K antagonists in the first 6 months. Thereafter, anticoagulation should be continued indefinitely with either low-molecular-weight heparin or oral vitamin K antagonists. Inferior vena cava filters are not routinely recommended and should only be used in patients who have a contraindication to anticoagulation. Patients who have had VTE and with persistent or recurrent dyspnea should be evaluated for recurrence of VTE or development of CTEPH. Patients with recurrent VTE should be anticoagulated indefinitely. Routine screening for CTEPH in asymptomatic patients is not recommended. Echocardiography often provides the first indication of the presence of pulmonary hypertension. Once presence of CTEPH is established by right-sided heart catheterization and perfusion imaging (ie, ventilation/perfusion scintigraphy, computed tomography angiography, or pulmonary angiography), patients should be referred early to a center with expertise, as it is potentially surgically curable by pulmonary endarterectomy. Those who are deemed inoperable after being evaluated may gain symptomatic benefit from drugs approved for idiopathic pulmonary arterial hypertension. Lung transplantation may also be an option for patients who are not candidates for pulmonary endarterectomy.

PMID: 21881392 [PubMed - in process]

The Timing, Extent, Progression and Regression of Deep Vein Thrombosis in Immobile Stroke Patients: observational Data from the CLOTS Multicentre Randomised Trials.

J Thromb Haemost. 2011 Aug 23;

Authors: Dennis M, Mordi N, Graham C, Sandercock P

Abstract
Background: Deep Vein Thrombosis (DVT) is an important complication of stroke but the evidence to support commonly used prophylactic strategies is conflicting. Objectives: To describe the incidence, extent, associated clinical features and evolution of DVT after stroke. Patients/Methods: The CLOTS trials 1 & 2 together randomised 5632 immobile stroke patients in 135 hospitals in nine countries. We screened patients for asymptomatic DVT with compression duplex ultrasound (CDU) at about 7-10 days and again at about 25-30 days after enrolment. Results: 641(11.4%) of 5632 patients had DVT detected on the first CDU at a median of 8(IQR 7-10) days after enrolment and an additional 176(3.1%) had a DVT on the second CDU at a median of 28(IQR 26-30) days. Of the 817 with DVTs, 289(35%) were symptomatic and 39(5%) had pulmonary embolism (PE) confirmed by imaging. 676 (83%) were unilateral, 141(17%) were bilateral, 322(39%) were limited to calf veins, 172(21%) were popliteal and 323(40%) were femoral. Of the 542 patients with DVT and a weak leg, the DVT affected the weaker leg in 396(73%), the stronger leg in 59(11%) and were bilateral in 87(16%). Of the 318 patients with a DVT detected on the first CDU who had a second scan, their DVT regressed in 148(47%), stayed the same in 140(44%) and progressed in just 30(9%). Conclusions: Although most DVTs develop within the 1(st) week, some develop later and some early DVTs progress. Any prophylaxis needs to be started early but ideally continued for at least 4 weeks.

PMID: 21883879 [PubMed - as supplied by publisher]

Massive and Submassive Pulmonary Embolism: Experience With an Algorithm for Catheter-Directed Mechanical Thrombectomy.

Ann Vasc Surg. 2011 Aug 30;

Authors: Nassiri N, Jain A, McPhee D, Mina B, Rosen RJ, Giangola G, Carroccio A, Green RM

Abstract
BACKGROUND: The role of catheter-directed mechanical thrombectomy (CDMT) for the treatment of massive pulmonary embolism (MPE) and submassive pulmonary embolism (SMPE) is not clearly defined. We report our experience with an algorithm for CDMT as a primary treatment in patients with MPE and SMPE. METHODS: We retrospectively reviewed our experience in treating MPE and SMPE in consecutive patients over a 2-year period (2008-2010). Patients with computed tomography angiography evidence of saddle, main branch, or ≥2 lobar pulmonary emboli in the setting of hypoxia, tachycardia, echocardiographic right heart strain, and/or cardiogenic shock underwent AngioJet CDMT, with or without adjunctive thrombolytic power-pulse spray. Outcomes, including angiographic success, clinical improvement, complications, and survival to discharge, were evaluated. RESULTS: Fifteen patients (8 men, 7 women; 14 SMPE, 1 SMPE) with a mean age of 59 years (range: 35-90 years) were treated for heart strain (100%), tachycardia (67%), hypoxia (67%), and cardiogenic shock (7%). Ten patients (67%) also received Alteplase power-pulse spray. Resolution of symptoms and improvement in heart strain were achieved in all patients. There were no in-hospital mortalities. Complications occurred in 3 patients (20%), including 2 patients with acute tubular necrosis and 1 patient with an intraoperative cardiac arrest. Average hospitalization was 9 days (range: 4-26 days). All patients were discharged on full anticoagulation. None required supplemental oxygen at discharge. CONCLUSION: CDMT as primary treatment of MPE and SMPE has a high rate of technical and clinical success in a high-risk patient population. Experience and strict patient selection criteria may improve therapeutic outcomes.

PMID: 21885244 [PubMed - as supplied by publisher]